known by a rising in the throat, which is for the most part erroneously
ascribed to worms, by pale urine, and by a disposition to shed tears, or
to laugh upon trifling occasions. The latter discovers itself by false
opinions of the nature and danger of the disease under which the patient
labours. Both these states of the nervous system occur frequently in the
gout and in the malignant state of fever. It is common to say, in such
cases, that patients have a complication of diseases; but this is not
true, for the hysterical and hypochondriacal symptoms are nothing but the
effects of one remote cause, concentrating its force chiefly upon the
nerves and muscles.
37. The _cutaneous_ state of fever. Dr. Sydenham calls a dysentery a
"febris introversa." Eruptions of the skin are often nothing but the
reverse of this introverted fever. They are a fever translated to the
skin; hence we find them most common in those countries and seasons in
which fevers are epidemic. The prickly heat, the rash, and the essere of
authors, are all states of misplaced fever. "Agues, fevers, and even
_pleurisies_ (says Mr. Townsend, in his Journey through Spain[12]), are
said often to terminate in scabies, and this frequently gives place to
them, returning, however, when the fever ceases. In adults it takes
possession of the hands and arms, with the legs and thighs, covering them
with a filthy crust." Small boils are common among the children in
Philadelphia, at the time the cholera infantum makes its appearance.
These children always escape the summer epidemic. The elephantiasis
described by Dr. Hillary, in his account of the diseases of Barbadoes, is
evidently a translation of an intermittent to one of the limbs. It is
remarkable, that the leprosy and malignant fevers of all kinds have
appeared and declined together in the same ages and countries. But
further, petechiæ sometimes appear on the skin without fever. Cases of
this kind, with and without hæmorrhages, are taken notice of by
Riverius[13], Dr. Duncan, and many other practical writers. They are
cotemporary or subsequent to fevers of a malignant complexion. They occur
likewise in the scurvy. From some of the predisposing, remote, and
exciting causes of this disease, and from its symptoms and remedies, I
have suspected it, like the petechiæ mentioned by Riverius, to be
originally a fever generated by human miasmata, in a misplaced state. The
hæmorrhages which sometimes accompany the scurvy, certainly arise from a
morbid state of the blood-vessels. The heat and quick pulse of fever are
probably absent, only because the preternatural excitement of the whole
sanguiferous system is confined to those extreme or cutaneous vessels
which pour forth blood. In like manner the fever of the small-pox deserts
the blood-vessels, as soon as a new action begins on the skin. Or perhaps
the excitability of the larger blood-vessels may be so far exhausted by
the long or forcible impression of the remote and predisposing causes of
the scurvy, as to be incapable of undergoing the convulsive action of
general fever.
[12] Vol. II. Dublin edition, p. 262.
[13] Praxis Medica, lib. xviii. cap. i.
With this I close my inquiry into the cause of fever. It is imperfect
from its brevity, as well as from other causes. I commit it to my pupils
to be corrected and improved.
"We think our fathers fools, so wise we grow.
Our wiser sons, _I hope_, will think us so."
AN ACCOUNT
OF THE
_Bilious Remitting Yellow Fever_,
AS IT
APPEARED IN PHILADELPHIA,
IN THE YEAR 1793.
Before I proceed to deliver the history of this fever, it will be proper
to give a short account of the diseases which preceded it.
The state of the weather during the first seven months of the year, and
during the time in which the fever prevailed in the city, as recorded by
Mr. Rittenhouse, will be inserted immediately after the history of the
disease.
The _mumps_, which made their appearance in December, 1792, continued to
prevail during the month of January, 1793. Besides this disease there
were many cases of catarrh in the city, brought on chiefly by the
inhabitants exposing themselves for several hours on the damp ground, in
viewing the aërial voyage of Mr. Blanchard, on the 9th day of the month.
The weather, which had been moderate in December and January, became cold
in February. The mumps continued to prevail during this month with
symptoms so inflammatory as to require, in some cases, two bleedings.
Many people complained this month of pains and swellings in the jaws. A
few had the scarlatina anginosa.
The mumps, pains in the jaws, and scarlatina continued throughout the
month of March. I was called to two cases of pleurisy in this month,
which terminated in a temporary mania. One of them was in a woman of
ninety years of age, who recovered. The blood drawn in the other case (a
gentleman from Maryland) was dissolved. The continuance of a tense pulse
induced me, notwithstanding, to repeat the bleeding. The blood was now
sizy. A third bleeding was prescribed, and my patient recovered. Several
cases of obstinate erysipelas succeeded inoculation in children during
this and the next month, one of which proved fatal.
Blossoms were universal on the fruit-trees, in the gardens of
Philadelphia, on the first day of April. The scarlatina anginosa
continued to be the reigning epidemic in this month.
There were several warm days in May, but the city was in general healthy.
The birds appeared two weeks sooner this spring than usual.
The register of the weather shows, that there were many warm days in
June. The scarlatina continued to maintain its empire during this month.
The weather was uniformly warm in July. The scarlatina continued during
the beginning of this month, with symptoms of great violence. A son of
James Sharswood, aged seven years, had, with the common symptoms of this
disease, great pains and swellings in his limbs, accompanied with a tense
pulse. I attempted in vain to relieve him by vomits and purges. On the
10th day of the month, I ordered six ounces of blood to be drawn from his
arm, which I observed afterwards to be very sizy. The next day he was
nearly well. Between the 22d and the 24th days of the month, there died
three persons, whose respective ages were 80, 92, and 96-1/2. The weather
at this time was extremely warm. I have elsewhere taken notice of the
fatal influence of extreme heat, as well as cold, upon human life in old
people. A few bilious remitting fevers appeared towards the close of this
month. One of them under my care ended in a typhus or chronic fever, from
which the patient was recovered with great difficulty. It was the son of
Dr. Hutchins, of the island of Barbadoes.
The weather, for the first two or three weeks in August, was temperate
and pleasant. The cholera morbus and remitting fevers were now common.
The latter, were attended with some inflammatory action in the pulse, and
a determination to the breast. Several dysenteries appeared at this time,
both in the city and in its neighbourhood. During the latter part of
July, and the beginning of this month, a number of the distressed
inhabitants of St. Domingo, who had escaped the desolation of fire and
sword, arrived in the city. Soon after their arrival, the influenza made
its appearance, and spread rapidly among our citizens. The scarlatina
still kept up a feeble existence among children. The above diseases were
universal, but they were not attended with much mortality. They prevailed
in different parts of the city, and each seemed to appear occasionally to
be the ruling epidemic. The weather continued to be warm and dry. There
was a heavy rain on the 25th of the month, which was remembered by the
citizens of Philadelphia, as the last that fell for many weeks
afterwards.
There was something in the heat and drought of the summer months which
was uncommon, in their influence upon the human body. Labourers every
where gave out (to use the country phrase) in harvest, and frequently too
when the mercury in Fahrenheit's thermometer was under 84°. It was
ascribed by the country people to the calmness of the weather, which left
the sweat produced by heat and labour to dry slowly upon the body.
The crops of grain and grass were impaired by the drought. The summer
fruits were as plentiful as usual, particularly the melons, which were of
an excellent quality. The influence of the weather upon the autumnal
fruits, and upon vegetation in general, shall be mentioned hereafter.
I now enter upon a detail of some solitary cases of the epidemic, which
soon afterwards spread distress through our city, and terror throughout
the United States.
On the 5th of August, I was requested by Dr. Hodge to visit his child. I
found it ill with a fever of the bilious kind, which terminated (with a
yellow skin) in death on the 7th of the same month.
On the 6th of August, I was called to Mrs. Bradford, the wife of Mr.
Thomas Bradford. She had all the symptoms of a bilious remittent, but
they were so acute as to require two bleedings, and several successive
doses of physic. The last purge she took was a dose of calomel, which
operated plentifully. For several days after her recovery, her eyes and
face were of a yellow colour.
On the same day, I was called to the son of Mrs. M'Nair, who had been
seized violently with all the usual symptoms of a bilious fever. I purged
him plentifully with salts and cremor tartar, and took ten or twelve
ounces of blood from his arm. His symptoms appeared to yield to these
remedies; but on the 10th of the month a hæmorrhage from the nose came
on, and on the morning of the 12th he died.
On the 7th of this month I was called to visit Richard Palmer, a son of
Mrs. Palmer, in Chesnut-street. He had been indisposed for several days
with a sick stomach, and vomiting after eating. He now complained of a
fever and head-ach. I gave him the usual remedies for the bilious fever,
and he recovered in a few days. On the 15th day of the same month I was
sent for to visit his brother William, who was seized with all the
symptoms of the same disease. On the 5th day his head-ach became
extremely acute, and his pulse fell to sixty strokes in a minute. I
suspected congestion to have taken place in his brain, and ordered him to
lose eight ounces of blood. His pulse became more frequent, and less
tense after bleeding, and he recovered in a day or two afterwards.
On the 14th day of this month I was sent for to visit Mrs. Leaming, the
wife of Mr. Thomas Leaming. I suspected at first that she had the
influenza, but in a day or two her fever put on bilious symptoms. She was
affected with an uncommon disposition to faint. Her pulse was languid,
but _tense_. I took a few ounces of blood from her, and purged her with
salts and calomel. I afterwards gave her a small dose of laudanum which
disagreed with her. In my note book I find I have recorded that "she was
worse for it." I was led to make this remark by its being so very
uncommon for a person, who had been properly bled and purged, to take
laudanum in a common bilious fever without being benefited by it. She
recovered, however, slowly, and was yellow for many days afterwards.
On the morning of the 18th of this month I was requested to visit Peter
Aston, in Vine-street, in consultation with Dr. Say. I found him on the
third day of a most acute bilious fever. His eyes were inflamed, and his
face flushed with a deep red colour. His pulse seemed to forbid
evacuations. We prescribed the strongest cordials, but to no purpose. We
found him, at 6 o'clock in the evening, sitting upon the side of his bed,
perfectly sensible, but without a pulse, with cold clammy hands, and his
face of a yellowish colour. He died a few hours after we left him.
None of the cases which I have mentioned excited the least apprehension
of the existence of a malignant or yellow fever in our city; for I had
frequently seen sporadic cases in which the common bilious fever of
Philadelphia had put on symptoms of great malignity, and terminated
fatally in a few days, and now and then with a yellow colour on the skin,
before or immediately after death.
On the 19th of this month I was requested to visit the wife of Mr. Peter
Le Maigre, in Water-street, between Arch and Race-streets, in
consultation with Dr. Foulke and Dr. Hodge. I found her in the last stage
of a highly bilious fever. She vomited constantly, and complained of
great heat and burning in her stomach. The most powerful cordials and
tonics were prescribed, but to no purpose. She died on the evening of the
next day.
Upon coming out of Mrs. Le Maigre's room I remarked to Dr. Foulke and Dr.
Hodge, that I had seen an unusual number of bilious fevers, accompanied
with symptoms of uncommon malignity, and that I suspected all was not
right in our city. Dr. Hodge immediately replied, that a fever of a most
malignant kind had carried off four or five persons within sight of Mr.
Le Maigre's door, and that one of them had died in twelve hours after the
attack of the disease. This information satisfied me that my
apprehensions were well founded. The origin of this fever was discovered
to me at the same time, from the account which Dr. Foulke gave me of a
quantity of damaged coffee which had been thrown upon Mr. Ball's wharf,
and in the adjoining dock, on the 24th of July, nearly in a line with Mr.
Le Maigre's house, and which had putrefied there to the great annoyance
of the whole neighbourhood.
After this consultation I was soon able to trace all the cases of fever
which I have mentioned to this source. Dr. Hodge lived a few doors above
Mr. Le Maigre's, where his child had been exposed to the exhalation from
the coffee for several days. Mrs. Bradford had spent an afternoon in a
house directly opposite to the wharf and dock on which the putrid coffee
had emitted its noxious effluvia, a few days before her sickness, and had
been much incommoded by it. Her sister, Mrs. Leaming, had visited her
during her illness at her house, which was about two hundred yards from
the infected wharf. Young Mr. M'Nair and Mrs. Palmer's two sons had spent
whole days in a compting house near where the coffee was exposed, and
each of them had complained of having been made sick by its offensive
smell, and Mr. Aston had frequently been in Water-street near the source
of the exhalation.
This discovery of the malignity, extent, and origin of a fever which I
knew to be attended with great danger and mortality, gave me great pain.
I did not hesitate to name it the _bilious remitting yellow fever_. I had
once seen it epidemic in Philadelphia, in the year 1762. Its symptoms
were among the first impressions which diseases made upon my mind. I had
recorded some of these symptoms, as well as its mortality. I shall here
introduce a short account of it, from a note book which I kept during my
apprenticeship.
"In the year 1762, in the months of August, September, October, November,
and December, the bilious yellow fever prevailed in Philadelphia, after a
_very hot summer_, and spread like a plague, carrying off daily, for some
time, upwards of twenty persons.
"The patients were generally seized with rigours, which were succeeded
with a violent fever, and pains in the head and back. The pulse was full,
and sometimes irregular. The eyes were inflamed, and had a yellowish
cast, and a vomiting almost always attended.
"The 3d, 5th, and 7th days were mostly critical, and the disease
generally terminated on one of them, in life or death.
"An eruption on the 3d or 7th day over the body proved salutary.
"An excessive heat and burning about the region of the liver, with cold
extremities, portended death to be at hand."
I have taken notice, in my note book, of the principal remedy which was
prescribed in this fever by my preceptor in medicine, but this shall be
mentioned hereafter.
Upon my leaving Mrs Le Maigre's, I expressed my distress at what I had
discovered, to several of my fellow-citizens. The report of a malignant
and mortal fever being in town spread in every direction, but it did not
gain universal credit. Some of those physicians who had not seen patients
in it denied that any such fever existed, and asserted (though its
mortality was not denied) that it was nothing but the common annual
remittent of the city. Many of the citizens joined the physicians in
endeavoring to discredit the account I had given of this fever, and for a
while it was treated with ridicule or contempt. Indignation in some
instances was excited against me, and one of my friends, whom I advised
in this early stage of the disease to leave the city, has since told me
that for that advice "he had hated me."
My lot in having thus disturbed the repose of the public mind, upon the
subject of general health, was not a singular one. There are many
instances upon record, of physicians who have rendered themselves
unpopular, and even odious to their fellow-citizens, by giving the first
notice of the existence of malignant and mortal diseases. A physician,
who asserted that the plague was in Messina, in the year 1743, excited so
much rage in the minds of his fellow-citizens against him, as to render
it necessary for him to save his life by retreating to one of the
churches of that city.
In spite, however, of all opposition, the report of the existence of a
malignant fever in the city gained so much ground, that the governor of
the state directed Dr. Hutchinson, the inspector of sickly vessels, to
inquire into the truth of it, and into the nature of the disease.
In consequence of this order, the doctor wrote letters to several of the
physicians in the city, requesting information relative to the fever. To
his letter to me, dated the 24th of August, I replied on the same day,
and mentioned not only the existence of a malignant fever, but the
streets it occupied, and my belief of its being derived from a quantity
of coffee which had putrified on a wharf near Arch-street. This, and
other information collected by the doctor, was communicated to the health
officer, in a letter dated the 27th of August, in which he mentioned the
parts of the city where the disease prevailed, and the number of persons
who had died of it, supposed by him to be about 40, but which subsequent
inquiries proved to be more than 150. He mentioned further, in addition
to the damaged coffee, some putrid hides, and other putrid animal and
vegetable substances, as the supposed cause of the fever, and concluded
by saying, as he had not heard of any foreigners or sailors being
infected, nor of its being found in any lodging-houses, that "it was not
an imported disease."
In the mean while the disease continued to spread, and with a degree of
mortality that had never been known from common fevers.
On the 25th of the month, the college of physicians was summoned by their
president to meet, in order to consult about the best methods of checking
the progress of the fever in the city. After some consideration upon the
nature of the disease, a committee was appointed to draw up some
directions for those purposes; and the next day the following were
presented to the college, and adopted unanimously by them. They were
afterwards published in most of the newspapers.
_Philadelphia, August 26th, 1793._
The college of physicians having taking into consideration the malignant
and contagious fever that now prevails in this city, have agreed to
recommend to their fellow-citizens the following means of preventing its
progress.
1st. That all unnecessary intercourse should be avoided with such persons
as are infected by it.
2d. To place a mark upon the door or window of such houses as have any
infected persons in it.
3d. To place the persons infected in the centre of large and airy rooms,
in beds without curtains, and to pay the strictest regard to cleanliness,
by frequently changing their body and bed linen, also by removing, as
speedily as possible, all offensive matters from their rooms.
4th. To provide a large and airy hospital, in the neighbourhood of the
city, for the reception of such poor persons as cannot be accommodated
with the above advantages in private houses.
5th. To put a stop to the tolling of the bells.
6th. To bury such persons as die of this fever in carriages, and in as
private a manner as possible.
7th. To keep the streets and wharves of the city as clean as possible. As
the contagion of the disease may be taken into the body, and pass out of
it without producing the fever, unless it be rendered active by some
occasional cause, the following means should be attended to, to prevent
the contagion being excited into action in the body.
8th. To avoid all fatigue of body and mind.
9th. To avoid _standing_ or _sitting_ in the sun; also in a current of
air, or in the evening air.
10th. To accommodate the dress to the weather, and to exceed rather in
warm, than in cool clothing.
11th. To avoid intemperance, but to use fermented liquors, such as wine,
beer, and cyder, in moderation.
The college conceive _fires_ to be very ineffectual, if not dangerous
means of checking the progress of this fever. They have reason to place
more dependence upon the burning of _gunpowder_. The benefits of
_vinegar_ and _camphor_ are confined chiefly to infected rooms, and they
cannot be used too frequently upon handkerchiefs, or in
smelling-bottles, by persons whose duty calls to visit or attend the
sick.
Signed by order of the college,
WILLIAM SHIPPEN, jun.
_Vice president_.
SAMUEL P. GRIFFITTS,
_Secretary_.
From a conviction that the disease originated in the putrid exhalations
from the damaged coffee, I published in the American Daily Advertiser, of
August 29th, a short address to the citizens of Philadelphia, with a view
of directing the public attention to the spot where the coffee lay, and
thereby of checking the progress of the fever as far as it was continued
by the original cause.
This address had no other effect than to produce fresh clamours against
the author; for the citizens, as well as most of the physicians of
Philadelphia, had adopted a traditional opinion that the yellow fever
could exist among us only by importation from the West-Indies.
In consequence, however, of a letter from Dr. Foulke to the mayor of the
city, in which he had decided, in a positive manner, in favour of the
generation of the fever from the putrid coffee, the mayor gave orders for
the removal of the coffee, and the cleaning of the wharf and dock. It was
said that measures were taken for this purpose; but Dr. Foulke, who
visited the place where the coffee lay, repeatedly assured me, that they
were so far from being effectual, that an offensive smell was exhaled
from it many days afterwards.
I shall pass over, for the present, the facts and arguments on which I
ground my assertion of the generation of this fever in our city. They
will come in more properly in the close of the history of the disease.
The seeds of the fever, when received into the body, were generally
excited into action in a few days. I met with several cases in which they
acted so as to produce a fever on the same day in which they were
received into the system, and I heard of two cases in which they excited
sickness, fainting, and fever within one hour after the persons were
exposed to them. I met with no instance in which there was a longer
interval than sixteen days between their being received into the body and
the production of the disease.
This poison acted differently in different constitutions, according to
previous habits, to the degrees of predisposing debility, or to the
quantity and concentration of the miasmata which had been received into
the body.
In some constitutions, the miasmata were at once a remote, a
predisposing, and an exciting cause of the disease; hence some persons
were affected by them, who had not departed in any instance from their
ordinary habits of living, as to diet, dress, and exercise. But it was
more frequently brought on by those causes acting in succession to each
other.